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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL, HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE ..(209)46$-3420 <br /> P O BOR 2009, STOCKTON,-CA 95201 <br /> PERMIT____EXPIRES 1 YEAR ;FR!L-DATE ISSUED. <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County fore permit to construct and/or install the work herein described. This <br /> application Is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San t <br /> Joaquin County Public <br /> HHealth Services. <br /> Job Address - � `�" zzdz?04 -•.3 -- City._9& .t Size/Acreage <br /> Owner's Name �TArdlC L'�l�,�S Address <br /> _ ze Phone <br /> Contractor._ USC:lQ Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ T f SYSTEM REPAIR ❑ OTHER ❑-'T'-Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C-1 Industrial ❑ Open Bottom ti ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> D Domestic/Private Cl Gravel Pack L7 Tracy Type of Casing Specifications <br /> f"1 Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ n <br /> Well Destruction O Well Diameter Sealing Material & Depth l� <br /> Depth Filler Material & Depth f <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION R I REPAIR./ADDITION DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) *� <br /> Installation will serve: ResidenceCommercial— Other <br /> Number of living units: Numbef of bedrooms <br /> Character of soil to a depth of 3 feet: Z Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity 4F No. Compartments <br /> PKG. TREATMENT PLT. ❑ v•y'.� . �� �7- Method of Disposal <br /> Distance to nearest: ` Well�� Foundatio Property Line " <br /> .LEACHING LINE L1 No. & Length`of lines Total length/size <br /> FILTER BED O Distance to.nearest: Well 'Foundation Property Line <br /> SEEPAGE PITS "y 11 DepthSize Number r <br /> .SUMPS Cl Distance to nearest. Well Foundation Property Line <br /> DISPOSAL PONDS `0.,- ^•=*.� . JT.....;� ��.. t <br /> S <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, aric i <br /> rules and regulations of the San Joaquin County \ <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not r <br /> " employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> . certifies the following: "I certify that in the performance of the work for.which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." r <br /> : The applicant must call for all repired ins 9ptions. Complete drawing on reverse side. <br /> Signed Title: Date: " <br /> FOR.DEPARTMENT USE ONLY <br /> Application Accepted by Date 3k,1910 Area <br /> Pit or Grout inspection by Date- Final Inspection by Date 3 <br /> Additional Comments: "'''"`:;' °1.;>,•,. ,: <br /> Applicant - Return all copies to: San Joaquin County ttiblicHealth <br /> s Services; Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., .P OBox 2009, Stockton, CA 95201 <br /> FEE r <br /> INFO AMOUNT DUE"'. AMOUNT REMITTED CASH RECEIVED BY / ATE PERMIT'fJ0. <br /> ♦ EH 13-24 1REV.I/R t4 <br />�`EH 14.28 <br />